Inspection on 13/09/05 for Agnes House

This inspection was carried out on 13th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Agnes House 15/08/07

Agnes House 02/05/06

Agnes House 04/04/05

Agnes House 10/11/04

Agnes House 07/06/04

Agnes House 05/02/04

Similar services:

Applegarth

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Agnes House Wyggestons Hospital Hinckley Road Leicester LE3 0UX Lead Inspector Keith Charlton Unannounced Thursday 13 September 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Agnes House Address Wyggestons Hospital Hinckley Road Leicester LE3 0UX 0116 2559173 0116 2543008 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Wyggestons Hospital Mrs Ellen Tebbutt Care Home 26 Category(ies) of OP Older Persons - 26 registration, with number PE(E) Physical Disability over 65 - 20 of places SI(E) Sensory Impairment over 65 - 5 Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: - Date of last inspection 4/4/2005 Brief Description of the Service: Agnes House is registered under the Care Standards Act 2000 and has been providing care since 1992. Agnes House is a purpose built home set in five acres of landscaped gardens in the centre of Leicester. It is registered for twenty six service users within the categories of old age, not falling within any other category, physical disability and sensory impairment. Accommodation is on two floors and these can be accessed by a shaft lift. The home offers a large lounge-dining area on the ground floor, which leads to a large well-fitted conservatory and this leads into a sensory garden. A further lounge is situated on the first floor. All the bedrooms offer en-suite facilities and all rooms are served by an emergency call system. The home enjoys the facilities and activities offered by William House, a sheltered housing scheme that is built adjacent to the home. These facilities include a chapel, Library and large meeting room. Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service user and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. A Team Leader was in charge. Planning for the Inspection included reading the Pre-Inspection Questionnaire completed by the Manager. The notifications of significant events sent to the Commission for Social Care Inspection by the home were also reviewed. There have been no complaints regarding the service since the last inspection. The inspector was given Comment Cards returned by service users and relatives which were all very positive about the standard of care provided by staff. The Inspection took place between 9.40 and 14.15 and included a tour of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke to eight residents, three members of staff and a relative. What the service does well: What has improved since the last inspection? Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 6 Staff have been appraised of the adult protection policy and have been trained in Dementia care have been asked by the Registered Manager to read and understand the Homes policies and procedures to ensure consistent care and action. Staff were observed to address service users in an appropriately friendly and respectful manner and service users said that this was the case. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not applicable. EVIDENCE: Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,10 Improvements in care planning would ensure residents’ needs are swiftly met. Residents’ dignity is protected. EVIDENCE: Service users stated that they thought staff carried out personal care in a friendly way. This was also observed. Comment Cards from service users and relatives also highly praised staff for their friendly care. Care Plans were generally detailed and include Risk Assessments regarding identified areas of risk though some sections did not have detail as to when some health care checks needed to be arranged. A care staff member spoken to had not read all service users Care Plans. Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14,15 Service users lead full and active lifestyle and can exercise choice. EVIDENCE: There were comments from service users that they like the activities. These are published and available to service users. A music and movement session was held during the inspection, which was well attended and appreciated by service users. There was a comment that having their own minibus would mean more frequent and easier to arrange outings. Service users said that there were no rules and they could please themselves about things – getting up and going to bed times etc and that staff encouraged them to retain their independence. Service users said that the food was good. The meal observed smelled tasty. There was a comment regarding the need for a rotating menu system. The Registered Manager said that service users are regularly asked about their food preferences and this would be documented in future at service users meetings and acted upon if necessary. Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Service users/their representatives can be confident their concerns will be properly attended to. EVIDENCE: Service users said that they could go to the Registered Manager if they had a problem and were confident it would be sorted out. Some Comment Cards from relatives stated they were not aware of the Complaints Procedure (though this is displayed on the Notice Board. The Registered Manager said she would ask staff to point this out to visitors). Staff spoken to knew to take their concerns further if abuse was suspected but were not aware of the existence of the Commission for Social Care Inspection to report concerns if necessary (though this information has been supplied by way of a policy and in the minutes of a staff meeting). The Registered Manager said this would be raised with staff. Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The facilities are homely and comfortable. EVIDENCE: Service users all said that they liked their bedrooms and they could bring in their own furniture. The well maintained garden and large conservatory were also appreciated. Facilities were clean and odour free. Service user said that this was always the case. Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30 The current staffing levels and training provided may lead to service users’ needs not being met. EVIDENCE: There were comments from service users that staffing levels were lower than before. This meant less time with staff with regard to personal care. Although staffing levels generally meet the Requirements of the Commission for Social Care Inspection staffing levels were found to have shifts with only three care staff (plus a senior in charge) on some shifts for the twenty six service users accommodated. Staff have now received training in the care of service users with dementia though training has not yet covered all service users health needs. Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Health and Safety systems do not fully protect the welfare needs of service users. EVIDENCE: Service users said that they felt safe in the home. Staff were observed to be following proper Moving and Handling techniques. Staff said that they had received Health and Safety training. There were written Risk Assessments for safe working practices. The frequency of fire drills was every six months when the Requirement is every three months and night staff had not had a fire drill in the last year. The Registered Manager said that night staff had been or were currently now appraised of fire procedure. Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 4 15 3 COMPLAINTS AND PROTECTION 4 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 2 Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 16 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard 7 27 30 38 Regulation 15 18 18 23 Requirement Care Plans need to contain all details of residents needs. Staffing levels need to be reviewed so that to meet the needs of service users. Staff training needs to include residents health conditions. Fire precautionary systems need to be comprehensive. Timescale for action 15/11/05 15/12/05 15/3/06 15/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 7 12 Good Practice Recommendations It is recommended that all care staff read residents care plans. It would assist with arranging outings if the service had its own transport, and to consider arranging activities for residents with memory needs. Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Agnes House C51 C01 S36495 Agnes House V248790 150905 Stage 4.doc Version 1.40 Page 18 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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